NEW ACCOUNT FORM (instructions)

NEW ACCOUNT FORM (instructions)
For your account to be opened promptly and accurately, please provide the information requested on the form as outlined
in the instructions below.
I. ACCOUNT REGISTRATION (CHECK ONE)
Additional documentation may be required to open certain account types. Use the supplemental sheets attached to this form to
identify all participants and their respective roles in the account. Contact your investment professional for more information.
II. USA PATRIOT ACT INFORMATION
This section MUST be completed in order to establish the account.
III-IV. ACCOUNT HOLDER INFORMATION AND SECONDARY ACCOUNT HOLDER INFORMATION
The legal address MUST be a street address. A post office box is not acceptable for a legal address. A legal address is the account
holder’s permanent residence address or, in the case of an entity, the place where it maintains a physical presence. For those accounts
opened for nonresident aliens and foreign entities, the legal address must be the same as the permanent residence address listed on
IRS Form W-8BEN or W-8IMY. You must provide annual income and net worth in the same manner. For instance, if the account
is a joint account, and you are providing a combined annual income, you must also provide a combined net worth.
NOTE: To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial
organizations to obtain, verify, and record information that identifies each person who opens an account. When you open an
account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask
you to provide a copy of your driver’s license or other identifying documents. The information you provide in this form may be used
to perform a credit check and verify your identity by using internal sources and third-party vendors. If additional space is needed,
attach a separate sheet.
V. INTERESTED PARTIES
If you would like to add an interested party to your account, provide the interested party’s contact information in this section.
Indicate if you would like the interested party to receive copies of your statements, confirmations, and proxies.
VI. TRANSACTION PROCESSING
Check the appropriate boxes to tell us how your proceeds or dividends/interest should be handled.
VII. ACCOUNT INFORMATION
Use this section to provide additional information about your account. Account investment objectives are defined as follows:
Income—An investment approach by which an investor generally seeks current income over time.
Long-Term Growth—An investment approach by which an investor generally seeks capital appreciation through buying and
holding securities over an extended period of time.
Short-Term Growth—An investment approach by which an investor generally seeks short-term capital gains through buying and
selling securities over a short period of time.
VIII. CASH MANAGEMENT
Check the appropriate boxes to tell us how your income and periodic principal distributions should be handled.
IX. U.S. TAXPAYER NUMBER CERTIFICATION
U.S. persons must sign the U.S. taxpayer certification built into the New Account Form. If the account is a JOINT account, you
must provide the Social Security Number or the Taxpayer Identification Number of the individual whose name appears first. For
custodial accounts, use the Social Security Number of the minor. If you are a nonresident alien or foreign entity, you should not sign
the taxpayer certification included in this form, and instead submit an IRS Form W-8BEN or W-8IMY with this application.
Nonresident alien joint accounts require IRS Form W-8BEN for each account holder. The account holder’s country of permanent
residence is the country where the account holder claims to be a resident for purposes of that country’s income tax. If a reduced rate
of withholding is being claimed under an income tax treaty, residency must be determined in the manner required by the treaty. If
the account holder does not have a tax residence in any country, the permanent residence is where the account holder normally
resides (or maintains an office for accounts not owned by individuals). The primary account owner whose Social Security Number
or Taxpayer Identification Number is used should sign the Taxpayer Certification on page 5.
X. SIGNATURES
Sign and date the form. The primary and secondary owners of a joint account must sign the form on page 5. Additional owners
must sign the additional participant form. For a custodial account, only the custodian needs to sign.
continues on next page
Pershing LLC, a subsidiary of The Bank of New York Mellon Corporation
Member FINRA, NYSE, SIPC
Page 1 of 8
FRM-NEW-ACCT-SS-9-08
PARTICIPANT INFORMATION SUPPLEMENT
Use one of the codes below to designate the participant role for the additional participant on an account.
EXEC–Executor
GPMM–General Partner/
Managing Member
GRNT–Grantor
GRDN–Guardian
IPTY–Interested Party
IMGR–Investment Manager
LHLD–Lien Holder
LPAR–Limited Partner
ADMN–Administrator
AGNT–Agent
BENF–Beneficiary
BORW–Borrower
CONS–Conservator
CUST–Custodian
DECD–Deceased
DPTR–Depositor
DRTR–Director
MNGR–Manager
MMBR–Member
MINR–Minor
OFCR–Officer
PTNR–Partner
PREP–Personal Representative
PLAD–Plan Administrator
PATN–Power of Attorney
PRM–Primary Account Holder
RIND–Responsible Individual
SEC–Secondary Account Holder
STLR–Settlor
SHLR–Shareholder
SPSR–Sponsor
TSTE–Trustee
IATJ–Investment Advisor/Transfer
on Death Joint
IATR–Investment Advisor/Trust
INDV–Individual
INVA–Investment
Advisor/Managed Account
JNTN–Joint
LLCP-Limited Liability
Corporation
LPAR-Limited Partnership
NPLC-Nonpurpose Loan
Corporate
NPLI-Nonpurpose Loan Individual
NPLJ-Nonpurpose Loan Joint
NPLP-Nonpurpose Loan
Partnership
NPLT-Nonpurpose Loan Trust
NPRO–Nonprofit Organization
N401-Prototype Individual 401(k)
N457-Nonqualified Deferred
Compensation Plan
N529-State Sponsored Higher
Education Plan
PART–Partnership
PRME-Prime Broker
PWRA–Power of Attorney
RETC–Third Party as Custodian
SIMPLE IRA
RETE–Third Party as Custodian
ERISA Account
RETG-Third Party as Custodian
IRA Guardian
RETH-Third Party as Custodian
403(b)(7)
RETI–Third Party as Custodian
IRA
RETN-Third Party as Custodian
Roth IRA Guardian
RETP–Third Party as Custodian
Prototype SEP
RETQ–Third Party as Custodian
QRP
RETR–Third Party as Custodian
Roth IRA
RETS–Third Party as Custodian
SARSEP and SEP
RETV-Third Party as Custodian
Education Savings
SOLE–Sole Proprietorship
TODI–Transfer on Death
Individual
TODJ–Transfer on Death Joint
TRST–Trust
FOR BROKER-DEALER USE ONLY
Provide investment professional and principal approvals.
ACCOUNT CATEGORY CODES (FOR OFFICE USE ONLY)
BKCL–Bank Collateral Account
BOLI-Bank Owned Life Insurance
BTRS-Bank Owned Life Insurance
Trust
CLUB–Investment Club
COD–Receive/Deliver Versus
Payment
COLI-Corporate Owned Life
Insurance
CONS-Conservatorship
CORN–Noncorporate Account
CORP–Corporation
CPPS–Corporate Pension or Profit
Sharing Plan
CTRS-Corporate Owned Life
Insurance Trust
CUST–Custodian
DLJC–Pershing LLC SIMPLE
Individual Retirement Account
(IRA)
DLJI–Pershing LLC IRA
DLJP–Pershing LLC SARSEP and
Prototype SEP
DLJQ–Pershing LLC Qualified
Retirement Plan (QRP)
DLJS–Pershing LLC SEP IRA
ESTT–Estate
EXMP–Exempt Organization
FINL–Financial Organization
GOVT–Government Entity/Agency
GRDN–Guardian
IACP–Investment
Advisor/Corporation
IACU–Investment
Advisor/Custodian
IAES–Investment Advisor/Estate
IAGU–Investment
Advisor/Guardian
IAGV–Investment Advisor/
Government Agency
IAIN–Investment
Advisor/Individual
IAJT–Investment Advisor/Joint
IANP–Investment
Advisor/Nonprofit Organization
IAPA–Investment
Advisor/Partnership
IAPP–Investment
Advisor/Corporate
Pension/Profit Sharing
IAPW–Investment Advisor/Power
of Attorney
IART–Investment
Advisor/Retirement Account
IASP–Investment Advisor/Sole
Proprietor
IATI–Investment Advisor/Transfer
on Death Individual
Pershing LLC, a subsidiary of The Bank of New York Mellon Corporation
Member FINRA, NYSE, SIPC
FRM-NEW-ACCT-SS-9-08
NEW ACCOUNT FORM
ACCOUNT NUMBER:
For office use only:
IP:
I. ACCOUNT REGISTRATION
RETIREMENT* (Skip to section II)
RETAIL (Select a type of retail account below)
Individual Account
Estate* Person or Entity Appointed to Act on Behalf of the Account: Administrator
Personal Representative
Special Administrator
Executor
Temporary Administrator Executrix
Trust* Establishment Date:
Trust Type:
Charitable
Revocable
Family
Testamentary
Irrevocable
Irrevocable Living
Living
Trustees:
Beneficiaries:
Can the trustees act independently?
Power of Attorney* Power of Attorney Name:
/
Custodian for Minor* State in Which Gift Was Given:
Date Gift Was Given:
Age Designated to Terminate:
Manner in Which Gift Was Given:
Trust
Exercise by Appointment
Will
Transfer by Fiduciary or Obligor
Created by Gift
Joint Tenant Account*
Are the account holders married to each other? Yes No
Tenancy Clause: Community Property
Community Property with Right of Survivorship
Joint Tenants with Right of Survivorship
Corporate Pension/Profit Sharing Plan*
Plan Name:
Trustees:
Beneficiaries:
Transfer on Death—Individual*
Agreement Execution Date:
/
/
/
/
Transfer on Death—Joint*
Agreement Execution Date:
Are the account holders married to each other? Yes No
Tenancy State:
Tenancy Clause:
Community Property
Community Property with Right of Survivorship
Joint Tenants with Right of Survivorship
Number Appointed to Account:
Yes No
/
Minor’s Date of Birth:
Select One:
/
/
Uniform Gift to Minors Act
Uniform Transfer to Minors Act
Tenancy State:
Number of Tenants:
Tenants by Entirety
Tenants in Common
Usufruct
Number of Tenants:
Tenants by Entirety
Tenants in Common
Usufruct
Additional Retail Types:
IRA Third Party*
Guardianship*
Partnership*
Investment Club*
Conservatorship*
Financial Organization*
Corporation*
Bank Collateral*
Nonprofit Organization*
Government Entity/Agency*
Exempt Organization*
Sole Proprietorship*
*Additional documentation may be required to open these account types. Contact your investment professional for more
Noncorporate*
Nonpurpose Loan
Limited Liability Company
Limited Partnership
information.
II. USA PATRIOT ACT INFORMATION
What is the source of funds for this account? Income from Earnings
Investment Proceeds
Gift
Sale of Business
Inheritance
Other
Pension/IRA/Retirement Savings
Spouse/Parent
Lottery/Gaming
Insurance Proceeds
Legal Settlement
Is this account a Private Banking Account as defined under the USA PATRIOT Act?
Is this an account for a Foreign Bank as defined under the USA PATRIOT Act?
If yes, is the bank a Central Bank?
Yes No
Yes No
Yes No
SPECIAL NOTE FOR NON-U.S. ACCOUNTS: With respect to assets custodied by Pershing on your behalf, you acknowledge that income and capital gains or distributions to you from his
account may be taxable in your home jurisdiction. You acknowledge to your financial organization and to Pershing that you have taken your own tax advice in this regard.
Is this account for a Foreign Financial Institution (e.g. non-U.S. bank; non-U.S. branch of a U.S. bank; broker-dealer; futures merchant; commodities introducing broker;
mutual fund; money transmitter or currency exchanger)?
Yes No
If yes, is this a Foreign Bank Account operating under an Offshore Banking License?
Yes No
If yes, is this a Foreign Bank Account operating under a banking license issued by a Non-Cooperative Country or Territory?
Yes No
If yes, is this a Foreign Bank Account operating under a banking license issued by a jurisdiction subject to Section 311 measures?
Yes No
If the answer to any of the three questions above is yes, how many people or entities* own 10% or more of the Bank (if its shares are not publicly traded)? _______
Are you or anyone with an interest in this account either (1) a senior military, governmental, or political official in a non-U.S. country, or (2) closely associated with an
immediate family member of such an official? Yes No If Yes, identify the name of the official, office held, and country: ____________________________
*If number is greater than zero, a Foreign Bank Beneficial Ownership form must accompany this request.
Page 1 of 7
NAW9
FRM-NEW-ACCT-SS-9-08
NEW ACCOUNT FORM
ACCOUNT NUMBER:
III. ACCOUNT HOLDER INFORMATION
PRIMARY ACCOUNT HOLDER
Name: ___________________________________________________________________ Person Entity
LEGAL ADDRESS
ATTN: _____________________________________________________
Address: ___________________________________________________
_________________________________________________________
_________________________________________________________
City: __________________________ State: ____ Zip/Postal Code: ______
Province/County/Subdivision: ________________________ Country: ______
Social Security Number or Taxpayer ID Number: __________________
MAILING ADDRESS (If different)
ATTN: _______________________________________________________
Address: _____________________________________________________
___________________________________________________________
___________________________________________________________
City: __________________________ State: ____ Zip/Postal Code: ________
Province/County/Subdivision: ________________________ Country: ________
Country of Citizenship: ____________________________________________________________
Country of Permanent Residence: _________________________________
Telephone Number (Home): ________________________________________________________
Telephone Number (Business): ____________________________________
E-mail: ____________________________________________
Gender: Male Female
Marital Status: Single Married
/
/
Date of Birth: ________________
EMPLOYMENT INFORMATION
Employed (EMPL)
Unemployed (UEMP) Occupation: ________________________________________ Years Employed: ________
Self-Employed (SEMP) Homemaker (HOME)
Retired (RETD)
Student (STDT)
Type of Business:_________________________________________________________
Employer’s Name: ___________________________________________________________________________________________ ATTN: ______________________________
Employer’s Address: _______________________________________________________________________________________________________________________________
City: ______________________________________ State: _______ Zip/Postal Code: ________________ Province/County/Subdivision: ____________ Country: __________
Employment Status:
FINANCIAL INFORMATION
Identify Verification Method Used:
Compliance Data Center Inc. Report (CDCR)
Internal Review (INRV)
Regulatory Data Corporation (RDCR)
Other ID Vendor (OTHR)
Annual Income:
Tax Bracket:
From: $ ________________ To: $ _______________ 0-15% (LWTB)
15.1%-32% (MDTB)
Net Worth (Excluding home):
From: $ ________________ To: $ ________________ 32.1%-50% (HITB)
Check box if aggregated with other joint tenants.
50.1% + (TPTB)
UNEXPIRED GOVERNMENT IDENTIFICATION
NOTE: Unexpired photo government identification should be provided for all nonresident aliens, along with an IRS Form W-8BEN.
ID Verification Comments: __________________________________________________________________________________________________________________________
GOVERNMENT PHOTO ID #1
Type of Unexpired Photo ID: ______________________________________________
GOVERNMENT PHOTO ID #2
Type of Unexpired Photo ID: _______________________________________________
ID Number: _____________________________________________________________
ID Number: _____________________________________________________________
Country of Issue: ________________________________________________________
Country of Issue: _________________________________________________________
State/Province/Subdivision of ID: __________________________________________
State/Province/Subdivision of ID: ___________________________________________
/
/
/
/
Date of Issue: _____________________
Date of Expiration: ___________________
/
/
/
/
Date of Issue __________________________
Date of Expiration: ________________
CORPORATE/BUSINESS INFORMATION
Corporate/Business ID Number: ________________________________________________
Formation Date of Corporation/Business: _________________________________
State/Province of Incorporation: _______________________________________________
Country of Incorporation:______________________________________________________
BROKER-DEALER AFFILIATIONS
Are you an employee of this broker-dealer? Yes No
Are you related to an employee at this broker-dealer? Yes... Employee name: ___________________________________________________________________________
No
Relationship: ___________________________________________________________________
Are you an employee of another broker-dealer? Yes... Broker-dealer name: ____________________________________________________________________________
No
Are you related to an employee at another broker-dealer? Yes... Broker-dealer name: ________________________________ Employee name:___________________
No
Relationship: __________________
Are you maintaining any other brokerage accounts?
Yes... With what firms(s) are you maintaining other brokerage accounts?___________________________________
No
Years of investment experience: __________________
Are you or any member of your immediate family affiliated with or employed by a member of a stock exchange or the Financial Industry Regulatory Authority?
Yes
No
If Yes, employer authorization is required. What is the affiliation? _________________________________________________________________________
Are you a senior officer, director, or 10% or more shareholder of a public company? Yes... Company name(s) ___________________________________________
No
___________________________________________
Pershing LLC, a subsidiary of The Bank of New York Mellon Corporation
Member FINRA, NYSE, SIPC
Page 2 of 7
FRM-NEW-ACCT-SS-9-08
NEW ACCOUNT FORM
ACCOUNT NUMBER:
IV. SECONDARY ACCOUNT HOLDER INFORMATION
SECONDARY ACCOUNT HOLDER
Name: ___________________________________________________________________ Person Entity
LEGAL ADDRESS
ATTN: _____________________________________________________
Address: ___________________________________________________
_________________________________________________________
_________________________________________________________
City: __________________________ State: ____ Zip/Postal Code: ______
Province/County/Subdivision: ________________________ Country: ______
Social Security Number or Taxpayer ID Number: ___________________
MAILING ADDRESS (If different)
ATTN: _______________________________________________________
Address: _____________________________________________________
___________________________________________________________
___________________________________________________________
City: __________________________ State: ____ Zip/Postal Code: ________
Province/County/Subdivision: ________________________ Country: ________
Country of Citizenship: ____________________________________________________________
Country of Permanent Residence: _________________________________
Telephone Number (Home): ________________________________________________________
Telephone Number (Business): ____________________________________
E-mail: ____________________________________________
Gender: Male Female
Marital Status: Single Married
/
/
Date of Birth: ________________
EMPLOYMENT INFORMATION
Employed (EMPL)
Unemployed (UEMP) Occupation: ________________________________________ Years Employed: _______
Self-Employed (SEMP) Homemaker (HOME)
Retired (RETD)
Student (STDT)
Type of Business: _________________________________________________________
Employer’s Name: ___________________________________________________________________________________________ ATTN: ______________________________
Employer’s Address: _______________________________________________________________________________________________________________________________
City: ______________________________________ State: ______ Zip/Postal Code: _______________ Province/County/Subdivision: ____________ Country:__________
Employment Status:
FINANCIAL INFORMATION
Identify Verification Method Used:
Compliance Data Center Inc. Report (CDCR)
Internal Review (INRV)
Regulatory Data Corporation (RDCR)
Other ID Vendor (OTHR)
Skip this section if aggregated information was already provided.
Annual Income:
Tax Bracket:
From: $ _________________ To: $ _________________ 0-15% (LWTB)
15.1%-32% (MDTB)
Net Worth (Excluding home):
From: $ _________________ To: $ _________________ 32.1%-50% (HITB)
50.1% + (TPTB)
UNEXPIRED GOVERNMENT IDENTIFICATION
NOTE: Unexpired photo government identification should be provided for all nonresident aliens, along with an IRS Form W-8BEN.
ID Verification Comments: __________________________________________________________________________________________________________________________
GOVERNMENT PHOTO ID #1
Type of Unexpired Photo ID: _____________________________________________
ID Number: ___________________________________________________________
Country of Issue: _______________________________________________________
State/Province/Subdivision of ID: ________________________________________
/
/
/
/
Date of Issue: ______________________
Date of Expiration: _________________
GOVERNMENT PHOTO ID #2
Type of Unexpired Photo ID: _________________________________________________
ID Number:________________________________________________________________
Country of Issue: ___________________________________________________________
State/Province/Subdivision of ID: _____________________________________________
/
/
/
/
Date of Issue: _________________________
Date of Expiration: ________________
BROKER-DEALER AFFILIATIONS
Are you an employee of this broker-dealer? Yes No
Are you related to an employee at this broker-dealer? Yes... Employee name: ___________________________________________________________________________
No
Relationship:____________________________________________________________________
Are you an employee of another broker-dealer? Yes... Broker-dealer name: ____________________________________________________________________________
No
Are you related to an employee at another broker-dealer? Yes... Broker-dealer name: ________________________________ Employee name: ___________________
No
Relationship: __________________
Are you maintaining any other brokerage accounts?
Yes... With what firms(s) are you maintaining other brokerage accounts?___________________________________
No
Years of investment experience: __________________
Are you or any member of your immediate family affiliated with or employed by a member of a stock exchange or the Financial Industry Regulatory Authority?
Yes
No
If Yes, employer authorization is required. What is the affiliation? _________________________________________________________________________
Are you a senior officer, director, or 10% or more shareholder of a public company? Yes... Company name(s) ___________________________________________
No
______________________________________________________
ADDITIONAL PARTICIPANTS
Are there more than two participants for this account? Yes... Fill out the Participant Information Supplemental sheet at the end of this form. No
Pershing LLC, a subsidiary of The Bank of New York Mellon Corporation
Member FINRA, NYSE, SIPC
Page 3 of 7
FRM-NEW-ACCT-SS-9-08
NEW ACCOUNT FORM
ACCOUNT NUMBER:
V. INTERESTED PARTIES
FIRST INTERESTED PARTY
SECOND INTERESTED PARTY
Name: __________________________________________ Person Entity
Name: __________________________________________________ Person Entity
Mailing Address: ____________________________________________________
Mailing Address: ____________________________________________________________
__________________________________________________________________
____________________________________________________________________________________________
__________________________________________________________________
____________________________________________________________________________________________
City:___________________________________ State:____ Zip/Postal Code: ______
City:___________________________________ State:____ Zip/Postal Code: _______________
Province/County/Subdivison:__________________________________________
Country: __________________________________________________________
Province/County/Subdivison: _________________________________________________
Country: __________________________________________________________________
Telephone Number: (Home) ___________________________________________
Telephone Number: (Home) ___________________________________________________
Telephone Number: (Business) _________________________________________
Telephone Number: (Business) ______________________________________________________
E-mail: ____________________________________________________________
E-mail: ___________________________________________________________________
Type of Notification:
Statement Proxy
Type of Notification:
Confirmation
Statement Proxy
Confirmation
VI. TRANSACTION PROCESSING
Money Market Fund or FDIC Bank Sweep. Fund/Bank Sweep Name: _________________________________________________________________________
How would you like to handle proceeds?
Remit
Hold in Account
Hold and Sweep to Money Market Fund... Fund name: ________________________________________________________________
How would you like to handle dividends/interest?
Hold
Remit (Indicate frequency/method/start date in the Cash Management section under Income Distribution).
VII. ACCOUNT INFORMATION
Will you be giving discretion over this account to another? Yes... Name: ______________________________________________________________ Relationship: _________________
No Have the required form(s) been submitted?
Yes
No
Risk Exposure: (check one)
Low
If the account is established for a trust, corporation, estate, or other entity, has a certificate of trust, corporate resolution,
Moderate letter of appointment, or other appropriate documentation establishing and delegating authority been submitted?
Yes
Speculation
No
High Risk
Please provide the names and addresses of your banks:
Account Investment Objectives: Income
Long-Term Growth
Short-Term Growth
Pershing LLC, a subsidiary of The Bank of New York Mellon Corporation
Member FINRA, NYSE, SIPC
Page 4 of 7
FRM-NEW-ACCT-SS-9-08
NEW ACCOUNT FORM
ACCOUNT NUMBER:
VIII. CASH MANAGEMENT
Method:
INCOME DISTRIBUTION
First-Party Check
Third-Party Check* (Provide name and address below)
ACH**
Journal* Account for journal: _______________________
Frequency: Annually
Bimonthly
Quarterly
Semiannually
Semimonthly
Monthly
First Payment Date: __________________________________
INFORMATION FOR THIRD-PARTY CHECK (If applicable)
ATTN:_________________________________________________________________
Method:
PRINCIPAL DISTRIBUTION
First-Party Check
Third-Party Check* (Provide name and address below)
ACH**
Journal* Account for journal: _______________________
Frequency: Annually
Bimonthly
Quarterly
Semiannually
Semimonthly
Monthly
First Payment Date: _______________________________ Amount: ______________
INFORMATION FOR THIRD-PARTY CHECK (If applicable)
ATTN: _________________________________________________________________
Name: ____________________________________________ Person Entity
Name: ____________________________________ Person Entity
Address: ______________________________________________________________
Address: _______________________________________________________________
_____________________________________________________________________
____________________________________________________________________________________________________________________
_____________________________________________________________________
____________________________________________________________________________________________________________________
City:____________________________ State:____Zip/Postal Code:______
City:____________________________ State:_____ Zip/Postal Code: _______
Province/County/Subdivison:_________________________Country____________________
Province/County/Subdivison:_________________________Country____________________
*Requires a completed letter of authorization.
**Requires a completed ACH authorization form.
IX. U.S. TAXPAYER NUMBER CERTIFICATION
This section is not to be used by nonresident aliens and foreign entities.
TAXPAYER CERTIFICATION: Under penalties of perjury, I certify that:
(1) the number shown on this form in Section III is my correct Social Security Number or Taxpayer Identification Number (or I am waiting for a number to be issued to me);
(2) I am not subject to backup withholding because (a) I am exempt from backup withholding or (b) I have not been notified by the Internal Revenue Service (IRS) that I am
subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
(3) I am a U.S. citizen or other U.S. person (defined below).
CERTIFICATION INSTRUCTIONS: You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have
failed to report all interest and dividends on your tax return. If you are an exempt payee (if you are unsure, ask us for a complete set of IRS instructions), write the words
“Exempt Payee” here: ______________________
Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
The signature provided below is that of the primary account holder.
Signature: __________________________________________________________________________________________ Date: __________________________
X. SIGNATURES
Please review your information, read the Agreement on Page 6, and sign below. Keep a copy for your records.
I ACKNOWLEDGE THAT THIS AGREEMENT CONTAINS A PREDISPUTE ARBITRATION CLAUSE, IN PARAGRAPHS 13 AND 14, ON PAGE 6.
Primary Account Holder’s Signature: ______________________________________________________________________ Date: __________________________
Secondary Account Holder’s Signature: ____________________________________________________________________ Date: __________________________
FOR BROKER-DEALER USE ONLY
Accepted: Investment Professional is Registered in the State of Client’s Residence
Investment Professional (Print name): __________________________________________________________________________________________________
Signature: __________________________________________________________________________________________ Date: __________________________
Principal (Print name): ______________________________________________________________________________________________________________
Signature: ___________________________________________________________________________________________ Date: _________________________
Pershing LLC, a subsidiary of The Bank of New York Mellon Corporation
Member FINRA, NYSE, SIPC
Page 5 of 7
FRM-NEW-ACCT-SS-9-08
TO: FINANCIAL ORGANIZATION AND ITS ASSIGNS:T
1. PROVISIONS IN THE EVENT OF FAILURE TO PAY OR DELIVER
Whenever I (we) do not, on or before the settlement date, pay in full for any security purchased for my (our) account, or deliver any security
sold for such account, you are authorized (subject to the provisions of any applicable statute, rule, or regulation):
(A) Until payment or delivery is made in full, to pledge, repledge, hypothecate, or rehypothecate, without notice, any or all securities which
you or your clearing agent may hold for me (either individually or jointly with others), separately or in common with other securities or
commodities or any other property, for the sum then due or for a greater or lesser sum and without retaining in your possession and control
for delivery a like amount of similar securities.
(B) To sell any or all securities which you or your clearing agent may hold for me (either individually or jointly with others), to buy in any or
all securities required to make delivery for my (our) account, or to cancel any or all outstanding orders or commitments for my (our) account.
2. CANCELLATION PROVISIONS
You are authorized, in your discretion, should I (we) die or should you for any reason whatever deem it necessary for your protection,
without notice, to cancel any outstanding orders in order to close out my (our) accounts, in whole or in part, or to close out any of the
commitments made on my (our) behalf.
3. GENERAL PROVISIONS
Any sale, purchase, or cancellation authorized hereby may be made according to your judgement and at your discretion on the exchange or
other market where such business is then usually transacted, at public auction, or at private sale without advertising the same and without
any notice, prior to tender, demand, or call. You may purchase the whole or any part of such securities free from any right of redemption,
and I (we) shall remain liable for any deficiency. It is further understood that any notice, prior to tender, demand, or call, from you shall not
be considered a waiver of any provision of this agreement. I (we) shall include any person executing this agreement.
4. SUCCESSORS
This agreement and its provisions shall be continuous, and shall inure to the benefit of your present organization, and any successor
organization or assigns, and shall be binding upon me (us) and/or the estate, executors, administrators, and assigns of my (our) account.
5. AGE
I (we), if an individual, represent that I (we) am (are) of full age.
6. INTEREST IN ACCOUNT
No one except me (us) has an interest in any of my (our) accounts with you unless such interest is revealed in the title of such account, and
in any case, I (we) have the interest indicated in such title.
7. ORDERS AND STATEMENTS
Reports of the execution of orders and statements of my (our) account shall be conclusive if not objected to in writing, the former within
two days and the latter within ten days, after forwarding by you to me (us) by mail or otherwise.
8. EXTRAORDINARY EVENTS
You shall not be liable for loss or delay caused directly or indirectly by war, natural disasters, government restrictions, exchange, or market
rulings, or other conditions beyond your control.
9. FEES AND CHARGES
I (we) agree to the fees and charges on the fee schedule received by me (us). You may change the fee schedule from time to time.
10. JOINT ACCOUNTS
If this is a joint account, unless we notify you otherwise and provide such documentation, as you require, the brokerage account(s) shall be
held by us jointly with rights of survivorship (payable to either or the survivor of us). Each joint tenant irrevocably appoints the other as
attorney-in-fact to take all action on his or her behalf and to represent him or her in all respects in connection with this Agreement. You
shall be fully protected in acting, but shall not be required to act upon the instructions of either of us. Each of us shall be liable, jointly and
individually, for any amounts due to you pursuant to this Agreement, whether incurred by either or both of us.
11. ADDRESS
Communications may be sent to me (us) at my (our) current address which is on file at your office, or at such other address as I (we) may
hereafter give you in writing. All communications so sent, whether by mail, telegraph, messenger, or otherwise, shall be deemed given to me
(us) personally, whether actually received or not.
12. RECORDING CONVERSATIONS
I (we) understand and agree that for our mutual protection you may electronically record any of my (our) telephone conversations.
13. ARBITRATION DISCLOSURES
THIS AGREEMENT CONTAINS A PREDISPUTE ARBITRATION CLAUSE. BY SIGNING AN ARBITRATION AGREEMENT THE PARTIES AGREE
AS FOLLOWS:
ALL PARTIES TO THIS AGREEMENT ARE GIVING UP THE RIGHT TO SUE EACH OTHER IN COURT, INCLUDING THE RIGHT TO A
TRIAL BY JURY, EXCEPT AS PROVIDED BY THE RULES OF THE ARBITRATION FORUM IN WHICH A CLAIM IS FILED.
ARBITRATION AWARDS ARE GENERALLY FINAL AND BINDING; A PARTY’S ABILITY TO HAVE A COURT REVERSE OR MODIFY AN
ARBITRATION AWARD IS VERY LIMITED.
THE ABILITY OF THE PARTIES TO OBTAIN DOCUMENTS, WITNESS STATEMENTS, AND OTHER DISCOVERY IS GENERALLY MORE
LIMITED IN ARBITRATION THAN IN COURT PROCEEDINGS.
THE ARBITRATORS DO NOT HAVE TO EXPLAIN THE REASON(S) FOR THEIR AWARD.
THE PANEL OF ARBITRATORS WILL TYPICALLY INCLUDE A MINORITY OF ARBITRATORS WHO WERE OR ARE AFFILIATED WITH
THE SECURITIES INDUSTRY.
THE RULES OF SOME ARBITRATION FORUMS MAY IMPOSE TIME LIMITS FOR BRINGING A CLAIM IN ARBITRATION. IN SOME
CASES, A CLAIM THAT IS INELIGIBLE FOR ARBITRATION MAY BE BROUGHT IN COURT.
THE RULES OF THE ARBITRATION FORUM IN WHICH THE CLAIM IS FILED, AND ANY AMENDMENTS THERETO, SHALL BE
INCORPORATED INTO THIS AGREEMENT.
14. ARBITRATION AGREEMENT
ANY CONTROVERSY BETWEEN YOU AND US SHALL BE SUBMITTED TO ARBITRATION BEFORE THE NEW YORK STOCK EXCHANGE, INC.,
ANY OTHER NATIONAL SECURITIES EXCHANGE ON WHICH A TRANSACTION GIVING RISE TO THE CLAIM TOOK PLACE (AND ONLY
BEFORE SUCH EXCHANGE), OR THE FINANCIAL INDUSTRY REGULATORY AUTHORITY. NO PERSON SHALL BRING A PUTATIVE OR
CERTIFIED CLASS ACTION TO ARBITRATION, NOR SEEK TO ENFORCE ANY PREDISPUTE ARBITRATION AGREEMENT AGAINST ANY
PERSON WHO HAS INITIATED IN COURT A PUTATIVE CLASS ACTION; OR WHO IS A MEMBER OF A PUTATIVE CLASS WHO HAS NOT
OPTED OUT OF THE CLASS WITH RESPECT TO ANY CLAIMS ENCOMPASSED BY THE PUTATIVE CLASS ACTION UNTIL; (I) THE CLASS
CERTIFICATION IS DENIED; (II) THE CLASS IS DECERTIFIED; OR (III) THE CUSTOMER IS EXCLUDED FROM THE CLASS BY THE COURT.
SUCH FORBEARANCE TO ENFORCE AN AGREEMENT TO ARBITRATE SHALL NOT CONSTITUTE A WAIVER OF ANY RIGHTS UNDER THIS
AGREEMENT EXCEPT TO THE EXTENT STATED HEREIN. THE LAWS OF THE STATE OF NEW YORK GOVERN.
Pershing LLC, a subsidiary of The Bank of New York Mellon Corporation
Member FINRA, NYSE, SIPC
Page 6 of 7
FRM-NEW-ACCT-SS-9-08
NEW ACCOUNT FORM Participant Information Supplement
ACCOUNT NUMBER:
I. ADDITIONAL PARTICIPANT
ADDITIONAL PARTICIPANT INFORMATION
Name: ___________________________________________________________________ Person Entity
Social Security Number or Taxpayer ID Number: __________________
Participant Role (See the instructions for the appropriate code): ___________________________
LEGAL ADDRESS
ATTN: _____________________________________________________
Address: ___________________________________________________
_________________________________________________________
_________________________________________________________
City: __________________________ State: ____ Zip/Postal Code: ______
Province/County/Subdivision: ________________________ Country: ______
MAILING ADDRESS (If different)
ATTN: _______________________________________________________
Address: _____________________________________________________
___________________________________________________________
___________________________________________________________
City: __________________________ State: ____ Zip/Postal Code: ________
Province/County/Subdivision: ________________________ Country: ________
Country of Citizenship:___________________________________________________________
Country of Permanent Residence: __________________________________
Telephone Number (Home): _______________________________________________________
Telephone Number (Business): ____________________________________
E-mail: ____________________________________________
Gender: Male Female
Marital Status: Single Married
/
/
Date of Birth: ________________
EMPLOYMENT INFORMATION
Employed (EMPL)
Unemployed (UEMP) Occupation: ________________________________________ Years Employed: _______
Self-Employed (SEMP) Homemaker (HOME)
Retired (RETD)
Student (STDT)
Type of Business:_________________________________________________________
Employer’s Name: ___________________________________________________________________________________________ ATTN: ______________________________
Employment Status:
Employer’s Address: _______________________________________________________________________________________________________________________________
City: ___________________________________________ State: _______ Zip/Postal Code: ________________ Province/County/Subdivision:________________ Country: _______
FINANCIAL INFORMATION
Identify Verification Method Used:
Compliance Data Center Inc. Report (CDCR)
Internal Review (INRV)
Regulatory Data Corporation (RDCR)
Other ID Vendor (OTHR)
Annual Income:
From: $ _______________ To: $ _____________ Net Worth (Excluding home):
From: $ _______________ To: $ _____________ Tax Bracket:
0-15% (LWTB)
15.1%-32% (MDTB)
32.1%-50% (HITB)
50.1% + (TPTB)
UNEXPIRED GOVERNMENT IDENTIFICATION
NOTE: Unexpired photo government identification should be provided for all nonresident aliens, along with an IRS Form W-8BEN.
ID Verification Comments: __________________________________________________________________________________________________________________________
GOVERNMENT PHOTO ID #1
Type of Unexpired Photo ID: __________________________________________________
ID Number:_________________________________________________________________
Country of Issue: ____________________________________________________________
State/Province/Subdivision of ID: _____________________________________________
GOVERNMENT PHOTO ID #2
Type of Unexpired Photo ID: __________________________________________
ID Number: _________________________________________________________
Country of Issue:_____________________________________________________
State/Province/Subdivision of ID: _______________________________________
/
/
/
/
Date of Issue: ______________________
Date of Expiration: ______________________
/
/
Date of Issue: _____________________
/
/
Date of Expiration: ______________
BROKER-DEALER AFFILIATIONS
Are you an employee of this broker-dealer? Yes No
Are you related to an employee at this broker-dealer? Yes... Employee name: ___________________________________________________________________________
No
Relationship: ___________________________________________________________________
Are you an employee of another broker-dealer? Yes... Broker-dealer name: ____________________________________________________________________________
No
Are you related to an employee at another broker-dealer? Yes... Broker-dealer name: ________________________________ Employee name:___________________
No
Relationship: __________________
Are you maintaining any other brokerage accounts? Yes... With what firms(s) are you maintaining other brokerage accounts?___________________________________
No
Years of investment experience: __________________
Are you or any member of your immediate family affiliated with or employed by a member of a stock exchange or the Financial Industry Regulatory Authority?
Yes
No
If Yes, employer authorization is required. What is the affiliation? _________________________________________________________________________
Are you a senior officer, director, or 10% or more shareholder of a public company? Yes... Company name(s) ___________________________________________
No
___________________________________________________________________
II. SIGNATURE (Required only if participant is a joint tenant)
Please review your information, read the Agreement on Page 6 of the New Account Form, and sign below. Keep a copy for your records.
I ACKNOWLEDGE THAT THIS AGREEMENT CONTAINS A PREDISPUTE ARBITRATION CLAUSE, IN PARAGRAPHS 13 AND 14, ON PAGE 6.
Joint Tenant’s Signature: _______________________________________________________________________________ Date: ____________________________
Pershing LLC, a subsidiary of The Bank of New York Mellon Corporation
Member FINRA, NYSE, SIPC
Page 7 of 7
FRM-NEW-ACCT-SS-9-08